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Statewide Executive Summary HealthChoice and Primary Adult Care Organizations

HEDIS® 2009

September 2009

Prepared by:

HealthcareData Company, LLC 600 Bent Creek Blvd., Suite 160 Mechanicsburg, PA 17050 (800) 472-5382 www.HDCdata.com

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

Department of Health and Mental Hygiene Maryland HealthChoice and Primary Adult Care Programs

HEDIS® 2009 Results – Executive Summary

TABLE OF CONTENTS

BACKGROUND ........................................................................................................................... 1

I. HEDIS METHODOLOGY ...................................................................................................... 3

II. HEDIS AUDIT PROTOCOL ................................................................................................. 5

III. MEASURES DESIGNATED FOR REPORTING.............................................................. 7

IV. MEASURE-SPECIFIC FINDINGS – EXPLANATION .................................................. 10

V. MEASURE-SPECIFIC FINDINGS ..................................................................................... 12 CHILDREN’S PREVENTION AND SCREENING ............................................................................... 12

Childhood Immunization Status (CIS) .................................................................................. 12 Well-Child Visits in the First 15 Months of Life (W15) ........................................................ 14 Well-Child Visits in the Third, Fourth, Fifth, and Sixth Years of Life (W34) ....................... 15 Adolescent Well-Care Visits (AWC) ..................................................................................... 16

RESPIRATORY CONDITIONS ........................................................................................................ 17 Appropriate Testing for Children with Pharyngitis (CWP) .................................................. 17 Appropriate Treatment for Children with Upper Respiratory Infection (URI) .................... 18 Use of Appropriate Medications for People with Asthma (ASM) ......................................... 19

MEMBER ACCESS ....................................................................................................................... 21 Children and Adolescents’ Access to Primary Care Practitioners (CAP) ........................... 21 Adults’ Access to Preventive/Ambulatory Health Services (AAP) ........................................ 23

WOMEN’S HEALTH .................................................................................................................... 25 Breast Cancer Screening (BCS) ............................................................................................ 25 Cervical Cancer Screening (CCS) ........................................................................................ 26 Chlamydia Screening in Women (CHL) ............................................................................... 27

PRENATAL AND POSTPARTUM CARE .......................................................................................... 29 Prenatal and Postpartum Care (PPC) .................................................................................. 29 Frequency of Ongoing Prenatal Care (FPC) ....................................................................... 31

DIABETES CARE ......................................................................................................................... 33 Comprehensive Diabetes Care (CDC).................................................................................. 33

AMBULATORY CARE (UTILIZATION) .......................................................................................... 37 Ambulatory Care (AMB) ....................................................................................................... 37

CALL SERVICES ......................................................................................................................... 39 Call Answer Timeliness (CAT) .............................................................................................. 39 Call Abandonment (CAB) ..................................................................................................... 40 Rationale: See Call Answer Timeliness ..................................................................................... 40

VI. HEALTHCHOICE AND PRIMARY ADULT CARE HEDIS 2009 RESULTS ............ 41

GENERAL OBSERVATIONS .......................................................................................................... 41 FUTURE CONSIDERATIONS AND RECOMMENDATIONS ................................................................. 42 HEDIS 2009 REPORTED RATES .................................................................................................... 43

TABLE A – HEALTHCHOICE ORGANIZATION HEDIS® 2009 MEASURES – REPORTED RATES .................................................................................................................. 44


HEDIS® 2009 Results – Executive Summary 1

Background The Maryland Medicaid program implemented HealthChoice, a comprehensive managed care program, in June of 1997 after receiving a waiver from the Centers for Medicare and Medicaid Services (CMS) of the requirements in §1115 of the Social Security Act. HealthChoice allows eligible Medicaid recipients to enroll in the participating managed care organization of their choice. There are currently seven organizations participating in HealthChoice, with a total of 538,024 enrollees as of December 31, 2008.

In July 2006, the Maryland Department of Health and Mental Hygiene (DHMH) combined two of its programs, Maryland Pharmacy Assistance and Maryland Primary Care, to form a new Medical Assistance program called Primary Adult Care (PAC). PAC offers health care services to low-income Maryland residents, 19 years of age and older, who are not eligible for full Medicaid benefits. Four organizations currently participate in PAC, with a total of 26,469 enrollees by the close of as of December 31, 2008.

Within DHMH, the HealthChoice & Acute Care Administration is responsible for the quality oversight of the HealthChoice and PAC programs. DHMH continues to measure HealthChoice program clinical quality performance and enrollee satisfaction using initiatives including HEDIS and CAHPS® reporting. Performance is measured at the organization level and on a statewide basis. HEDIS and CAHPS results are incorporated annually into a HealthChoice Health Plan Performance Report Card developed to assist HealthChoice enrollees to make comparisons when selecting a health plan. In 2007, DHMH announced its intention to collect HEDIS results from each organization offering Primary Adult Care (PAC) for a subset of the HEDIS measures already being reported by HealthChoice organizations. All seven HealthChoice organizations reported HEDIS in 2009. Three PAC organizations reported HEDIS in 2009; the fourth intends to report in 2010.

Organizations reporting HEDIS in 2009

Acronym used in this report Organization name HealthChoice PAC

ACC AMERIGROUP Community Care X DIA Diamond Plan X JMS Jai Medical Systems X X MPC Maryland Physicians Care X X

MSFC MedStar Family Choice X PP Priority Partners X

UHC UnitedHealthcare X X

Healthcare Effectiveness Data and Information Set (HEDIS) is one of the most widely used sets of health care performance measures in the United States. The program is developed and maintained by the National Committee for Quality Assurance (NCQA). NCQA develops and publishes specifications for data collection and results calculation in order to promote a high degree of standardization of HEDIS results. NCQA requires that the reporting entity register with NCQA and undergo a HEDIS Compliance AuditTM. To ensure standardized audit methodology, only NCQA-licensed organizations using NCQA-certified auditors may conduct a HEDIS Compliance Audit. The audit conveys sufficient integrity to HEDIS data, such that it can be released to the public to provide consumers and purchasers with a means of comparing health care organization performance.

HEDIS Compliance AuditTM is a trademark of the National Committee for Quality Assurance (NCQA).



DHMH contracted with HealthcareData Company, LLC (HDC), an NCQA-certified Licensed Organization, to conduct HEDIS Compliance Audits of all HealthChoice and PAC organizations and to create audit summary and HEDIS results analysis reports.

The Consumer Assessment of Health Plans Survey (CAHPS) is also sponsored by NCQA. DHMH contracts with a certified NCQA survey vendor to administer the survey to a random selection of HealthChoice and PAC enrollees.

Measures selected by DHMH for HealthChoice Reporting DHMH required HealthChoice managed care organizations to report 20 HEDIS measures for services rendered in calendar year 2008 to Maryland Medical Assistance HealthChoice enrollees. DHMH selected these measures because they provide meaningful managed care organization comparative information and they measure performance pertinent to DHMH’s priorities and goals.

Effectiveness of Care Childhood Immunization Status (CIS) Breast Cancer Screening (BCS) Cervical Cancer Screening (CCS) Comprehensive Diabetes Care (CDC), all indicators except HbA1c good control (<7.0%) Use of Appropriate Medications for People with Asthma (ASM) Appropriate Treatment for Children with Upper Respiratory Infection (URI) Appropriate Testing for Children with Pharyngitis (CWP) Chlamydia Screening in Women (CHL)

Access/Availability of Care Adults' Access to Preventive/Ambulatory Health Services (AAP) Children and Adolescents' Access to Primary Care Practitioners (CAP) Prenatal and Postpartum Care (PPC) Call Answer Timeliness (CAT) Call Abandonment (CAB) Initiation and Engagement of Alcohol and Other Drug Dependence Treatment1 (IET)

Use of Services Frequency of Ongoing Prenatal Care (FPC) Well-Child Visits in the First 15 Months of Life (W15) Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life (W34) Adolescent Well-Care Visits (AWC) Ambulatory Care (AMB) Identification of Alcohol and Other Drug Services1 (IAD)

Measures selected by DHMH for Primary Adult Care (PAC) performance reporting

Three organizations participated in DHMH’s Quality and Performance Evaluation System. For 2009, measures were selected for reporting based on applicability to NCQA Accreditation scoring as well as survey or administrative-only data capture.

Breast Cancer Screening (BCS) Cervical Cancer Screening (CCS) Comprehensive Diabetes Care (CDC), all indicators except HbA1c good control (<7.0%) Adults’ Access to Preventive / Ambulatory Health Services (AAP)

1. Since these are new test measures, they will not be publicly reported for HEDIS 2009. CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality.



I. HEDIS Methodology Guidelines for data collection and measure calculation are described in Volume 2: Technical Specifications. Measure-specific HEDIS specifications are also contained in Volume 2.

Data collection: The organization or contracted vendor pulls together all data sources, typically into a data warehouse, against which HEDIS software programs are applied to calculate measures. Three approaches may be taken for data collection:

Administrative data: Data from transaction systems (claims, encounters, enrollment, practitioner) is collected in an ongoing manner.

Supplemental data: Supplemental data is considered administrative data for HEDIS calculation purposes. Supplemental data, including immunization databases, public agency databases, laboratory results, historical data, vendor data, and disease/case management data may be used in accordance with NCQA guidelines.

Medical record data: Data abstracted from paper or electronic medical records may be applied to certain measures. HEDIS specifications describe statistically sound methods of sampling, so that only a subset of the eligible population’s medical records needs to be chased. Sample size reduction is an option put forth by NCQA to help organizations reduce the cost of medical record review.

Measure calculation: Administrative calculation methods are specified for all measures selected by DHMH for reporting. Hybrid calculation methods are specified, in addition to administrative methods, for the following measures selected by DHMH for HEDIS reporting:

Childhood Immunization Status (CIS) Cervical Cancer Screening (CCS) Comprehensive Diabetes Care (CDC)—HbA1c testing; HbA1c poor control >9.0;

HbA1c control <8.0* Comprehensive Diabetes Care (CDC)—Eye exam Comprehensive Diabetes Care (CDC)—LDL-C screening; LDL-C level <100mg/dL* Comprehensive Diabetes Care (CDC)—Medical attention for nephropathy Comprehensive Diabetes Care (CDC)—Blood pressure level <140/90 mm Hg;

Blood pressure level <130/80 mm Hg* Prenatal and Postpartum Care (PPC) Frequency of Ongoing Prenatal Care (FPC) Well-Child Visits in the First 15 Months of Life (W15) Well-Child Visits in the Third, Fourth, Fifth, and Sixth Years of Life (W34) Adolescent Well-Care Visits (AWC)

* An organization must use the same method for these indicators.

No one approach to measure calculation or data collection is considered superior to another and the use of the hybrid method is optional. From organization to organization, the percentages of data obtained from one data source versus another are highly variable, making it inappropriate to make across-the-board statements about the need for, or positive impact of one method versus another. In fact, an organization’s yield from the hybrid method may impact the final rate by only a few percentage points, an impact that is also achievable through improvement of administrative data systems.



Supplemental data sources used by various organizations included the Maryland ImmuNet (state immunization registry), laboratory results data (provided by laboratory services vendor), QI department medical record review data, and case management data for diabetes and prenatal care.

The following table shows the use of the administrative or hybrid method.

ACC DIA JMS-HC

MPC- HC MSFC PP UHC-

HC JMS-PAC

MPC-PAC

UHC-PAC

CIS H H H H H H H CCS H H H H H H H A A A CDC– HbA1c testing and/or control

H H H H H H H A H A

CDC– Eye exam H H H H H H H A H A

CDC– LDL-C testing and/or control

H H H H H H H A H A

CDC–Nephropathy H H H H H H H A H A

CDC–Blood pressure H H H H H H H A H A

PPC H H H H H H H FPC H H H H H H H W15 H H H H H H H W34 H H H H H H H AWC H H H H H H H

H- Hybrid; A-Administrative



II. HEDIS Audit Protocol NCQA publishes Volume 5: HEDIS Compliance AuditTM: Standards, Policies, and Procedures. The main components of the audit are described below.

Offsite preparation for the onsite audit:

Conference call: A conference call is held early in the audit season to introduce key personnel, review the onsite agenda, identify session participants, and determine a plan to audit data sources used for HEDIS.

HEDIS Roadmap review: The auditor reviews the Roadmap prior to the onsite audit in order to make preliminary assessments regarding IS compliance and to identify areas requiring follow-up at the onsite audit.

Information Systems (IS) standards compliance: The onsite portion of the HEDIS Audit expands upon information gleaned from the HEDIS Roadmap to enable the auditor to make conclusions about the organization’s compliance with IS standards. IS standards, describing the minimum requirements for information systems and processes used in HEDIS data collection, are the foundation on which the auditor assesses the organization’s ability to report HEDIS data accurately and reliably. The auditor reviews data collection and management processes, including the monitoring of vendors, and makes a determination regarding data soundness and completeness of data to be used for HEDIS reporting.

HEDIS Measure Determination (HD) standards compliance: Both onsite and offsite activities are used to determine compliance with HD standards. HD standards are used to assess the organization’s adherence to HEDIS Technical Specifications and report-production protocols. The auditor confirms the use of NCQA-certified software. (As of HEDIS 2009, all Maryland Medicaid organizations used certified software to produce HEDIS reports.) The auditor reviews the organization’s sampling protocols (if the hybrid method is used). Later in the audit season, the auditor reviews HEDIS results for algorithmic compliance and performs benchmarking against NCQA-published means and percentiles.

Supplemental data (IS 5.0) audit: This HEDIS audit protocol includes primary source verification of any nonstandard data sources. The auditor determines if the data is external-standard, external-nonstandard, or internal-nonstandard. The auditor performs a primary source verification of nonstandard data before approving it for HEDIS use.

Medical record review validation: The HEDIS Compliance AuditTM includes a protocol to validate the integrity of data obtained from medical record review (MRR) for any measures calculated using the hybrid method. Medical record findings are compared to the respective completed abstraction forms for a sample of positive numerator events. If any errors are found, a statistical T-test is used to determine if the measure is biased. As an additional validation, exclusions may be validated for hybrid measures specifying exclusions (CIS, CCS, CDC).

The audit may also include a convenience sample of medical records for the purpose of finding procedural errors early in the medical record abstraction process so that timely corrective action can be made.

Audit designations: A HEDIS audit results in audited rates or calculations at the measure level and indicate if the measure can be publicly reported. All measures selected for reporting or required by a state or federal program must have a final, audited result. The auditor approves the rate or report status of each measure included in the report, as shown in the following table of audit results for HEDIS measures.



Rate/Result Comment

0–XXX Reportable rate or numeric result for HEDIS measures

NR

Not Reported: 1. Plan chose not to report * 2. Calculated rate was materially biased 3. Plan not required to report

NA Small Denominator: The organization followed the specifications but the denominator was too small to report a valid rate

NB No Benefit: The organization did not offer the health benefits required by the measure (e.g., mental health or chemical dependency)

* An organization may exercise this option only for those measures not included in the measurement set required by DHMH.

Bias Determination: If the auditor determines that a measure is biased, the organization cannot report a rate for that measure and the auditor assigns the designation of NR. Bias is based on the degree of data completeness for the data collection method used. NCQA has defined three bias determination rules, specific to measures, as delineated in Appendix 8 of Volume 5: HEDIS Compliance AuditTM: Standards, Policies and Procedures.

Final audit opinion: At the close of the audit, the auditor renders the Final Audit Opinion, containing a Final Audit Statement along with measures rates/designations and comments housed in the Audit Review Table.



III. Measures Designated for Reporting Annually DHMH determines the set of measures required for HEDIS reporting. Measures are selected because they provide meaningful comparative information relevant to DHMH priorities and goals.

For HealthChoice performance reporting in 2009, DHMH selected 20 measures for data collection and calculation. DHMH also announced to the participating organizations the department’s intent to report 18 of these measures. Two of the measures, Initiation and Engagement of Alcohol and Other Drug Dependence Treatment (IET) and Identification of Alcohol and Other Drug Services (IAD), are newly required for data collection and calculation in 2009, considered “test” measures, and will not be publicly reported. After reviewing first-year (2009) results, DHMH intends to make a decision whether or not to publicly report these measures’ results in 2010. For PAC performance reporting in 2009, DHMH selected four measures for data collection and calculation.

Measures designated for HEDIS 2009 data collection and calculation are listed in the following table. The table shows the first year of trending (found in Section V. of this report). A notation of <2005 is used to indicate that the measure has been reported since at least 2005. (Additional historical trending can be found in Statewide Analysis Reports from prior years. Measures discontinued by NCQA are not displayed in this table or in Section V.)

HEDIS Measures Reporting History

NC

QA

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QA

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Measure name

Indicators (Indicators reported for HEDIS but not included in this report are italicized.)

Hea

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PAC

rep

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Immunization Status

DTaP IPV MMR Hib Hepatitis B VZV Combination 2 (DTaP, IPV, MMR, Hib, hepatitis B, VZV)

< 2005

EOC CIS Childhood Immunization Status

Pneumococcal conjugate Combination 3 (DTaP, IPV, MMR, Hib, hepatitis B, VZV, pneumococcal conjugate)

2006 Pheumococcal conjugate was introduced by HEDIS in 2006 and adopted by DHMH for reporting that year. A new Combination 3 included this antigen.

UOS W15 Well-Child Visits in the First 15 Months of Life 2

Zero visits One visit Two visits Three visits Four visits Five visits Six or more visits DHMH nonHEDIS measure: Five visits and six or more visits (additive rate)

< 2005

1. EOC: Effectiveness of Care; AAC: Access/Availability of Care; UOS: Use of Services 2. NCQA considers these to be EOC-like measures.



NC

QA

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NC

QA

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Measure name


Hea

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hist

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PAC

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UOS W34

Well-Child Visits in the Third, Fourth, Fifth, and Sixth Years of Life 2

< 2005

UOS AWC Adolescent Well-Care Visits 2 < 2005

EOC CWP Appropriate Testing for Children with Pharyngitis

2007

EOC URI Appropriate Treatment for Children with Upper Respiratory Infection

2007

EOC ASM Use of Appropriate Medications for People with Asthma

5-9 years of age 10-17 years of age 18-56 years age Total

2006 with revised NCQA specifications

AAC CAP

Children and Adolescents' Access to Primary Care Practitioners 2

12-24 months of age 25 months to 6 years of age 7-11 years of age 12-19 years of age

2007 with revised specifications

AAC AAP Adults' Access to Preventive /Ambulatory Health Services 2

20-44 years of age 45-65 years of age

2007 with revised specifications 2009

EOC BCS Breast Cancer Screening 2007 with revised

specifications 2009

EOC CCS Cervical Cancer Screening 2007 2009

EOC CHL Chlamydia Screening in Women 16-20 years of age 2007

EOC CHL Chlamydia Screening in Women

2009: 21-25 years of age 2007-2008: 21-24 years of age 2007

EOC CHL Chlamydia Screening in Women

2009: Total (16-24 years of age) 2007-2008: Total (16-25 years of age)

2007

AAC PPC Prenatal and Postpartum Care 2 Timeliness of prenatal care < 2005

AAC PPC Prenatal and Postpartum Care 2 Postpartum care < 2005

UOS FPC Frequency of Ongoing Prenatal Care 2

<21 percent of expected visits 21 percent of expected visits 41 percent of expected visits 61 percent of expected visits >81 percent of expected visits

< 2005

EOC CDC Comprehensive Diabetes Care HbA1c testing < 2005 2009

EOC CDC Comprehensive Diabetes Care HbA1c poor control (>9.0%) < 2005 2009

1. EOC: Effectiveness of Care; AAC: Access/Availability of Care; UOS: Use of Services 2. NCQA considers these to be EOC-like measures.



NC

QA

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NC

QA

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Measure name


Hea

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PAC

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EOC CDC Comprehensive Diabetes Care HbA1c control (<8.0%)

2009 introduction by NCQA with adoption by DHMH for public reporting

2009

EOC CDC Comprehensive Diabetes Care Eye exam (retinal) performed < 2005 2009

EOC CDC Comprehensive Diabetes Care LDL-C screening 2007 with revised

specifications 2009

EOC CDC Comprehensive Diabetes Care LDL-C control (<100mg/dL) 2007 with revised

specifications 2009

EOC CDC Comprehensive Diabetes Care Medical attention for nephropathy 2007 with revised

specifications 2009

EOC CDC Comprehensive Diabetes Care

Blood pressure control (<130/90 mm Hg)


2009

EOC CDC Comprehensive Diabetes Care

Blood pressure control (<140/90 mm Hg)


2009

AAC IET

Initiation and Engagement of Alcohol and Other Drug Dependence Treatment

Initiation: 13-17 years of age 18+ years of age Total (ages 13-65)

2009

UOS IAD Identification of Alcohol and Other Drug Services

Any services Inpatient services Intensive Outpatient/Partial

Hospitalization Outpatient/ED

2009

UOS AMB Ambulatory Care

Outpatient visits ED visits Ambulatory Surgery/Procedures Observation Room Stays

2007; continued as a testing measure through 2008

AAC CAB Call Abandonment 2006

AAC CAT Call Answer Timeliness 2006

1. EOC: Effectiveness of Care; AAC: Access/Availability of Care; UOS: Use of Services



IV. Measure-Specific Findings – Explanation Metrics: Two metrics are calculated to accompany the organization-specific scores:

• Maryland Average Reportable Rate (MARR) • National HEDIS Mean (NHM)*

Maryland Average Reportable Rate (MARR): The MARR is an average of the HealthChoice organization’s rates, as reported to NCQA. In most cases, all seven organizations contributed a rate to the average. Where one or more organizations reported NA or NR instead of a rate, the average consisted of fewer than seven component rates. A MARR was not calculated for PAC organizations as only three organizations reported; with this few organizations reporting, an average could be easily be skewed by one unusual rate.

National HEDIS Mean (NHM)*: The mean value is taken from NCQA’s HEDIS Audit Means, Percentiles and Ratios – Medicaid, posted in the first quarter of each year to the NCQA Web site, http://www.ncqa.org/tabid/334/Default.aspx. The NCQA data set shows prior-year rates for each measure displayed as the mean rate and the rate at the 10th, 25th, 50th, 75th, and 90th percentiles. HEDIS 2008 Means, Percentiles, and Ratios pertinent to this report can be found in Appendix A.

NCQA averages the rates of all organizations submitting data via the IDSS system, regardless of the method of calculation (administrative or hybrid) and regardless of whether the organization elected to publicly report its data. NCQA’s method is the same as that used for the MARR, but on a larger scale.

Note: Certain table rows (e.g., age categories) are not displayed if fewer than 30 organizations report valid rates. However, organizations without enough members in a specific age group for reporting could have enough members dispersed through all the age categories to report a total; therefore, in these reports, the totals are not necessarily equal to the sum of the age categories.

NCQA’s Means, Percentiles, and Ratios can be found in Appendix A.

* This was referred to as the National Medicaid HEDIS Mean (NMH) in previous Statewide Analysis Reports.

Cautionary note in regards to application of the NHM: Based on what HDC has learned through the HEDIS audit process about state enrollment practices, there are two distinct groups of Medicaid HEDIS reporting entities: those from states that cease Medicaid eligibility upon Medicare eligibility (age 65), i.e., Maryland, and those that do not. In our experience auditing CAHPS sample frames, health plans that do not cease enrollment at age 65 have approximately 20% of members age 65 and older.

The effect of this large older cohort on an organization’s rates has not been studied.

Among measures selected by DHMH for HEDIS/CAHPS reporting, the following HEDIS specifications include (or do not exclude) members over the age of 65 (listed here with the age specification):

Breast Cancer Screening (ages 40-69) Comprehensive Diabetes Care (ages 18-75) CAHPS 4.0H Adult Survey (ages 18 and older)



Year-to-year trending: Year-to-year trending is possible when specifications remain consistent from year to year, with the exception of expected updates to industry-wide coding systems. For each measure, up to a five-year trend is displayed, where available.

In Statewide Analysis Reports through 2008, prior-year results were removed from trending tables upon NCQA’s significant revision of specifications. Beginning with 2009, prior-year results will be retained in the trending tables, regardless of specification changes. The prior-year results under different specifications will be shown in italics.

Performance trends at the organization level are juxtaposed with the trends for the MARR and the NHM for the same measurement year. Trending for Diamond Plan (DIA) started in 2006 because the number of members did not become significant until 2005.

Rounding of figures: Beginning with 2008, rates are rounded to one decimal point using the rate/ratio reported to NCQA. In addition, the 2007 NHM is displayed at one decimal point of specificity. This rounding corresponds to the rounding used by NCQA for the NHM. Where any two or more rates are identical at this level of detail, an additional decimal place of detail is provided.

Audit designation other than a rate/ratio: According to NCQA reporting protocols, NA or NR may replace a rate. Please see page 6 for defined uses of these audit designations.

Organization of data: Comparative results for HEDIS 2009 are shown on the following pages. In this report, an attempt was made to group and sequence measures by like populations or functions as follows:

Children’s Prevention and Screening: CIS, W15, W34, AWC Respiratory Conditions: CWP, URI, ASM Member Access: CAP, AAP Women’s Health: BCS, CCS, CHL Prenatal and Postpartum Care: PPC, FPC Diabetes: CDC Ambulatory Care (utilization): AMB Call Services: CAB, CAT

Sources of accompanying information:

Description – The source of the text, with minimal editing, is NCQA’s HEDIS 2009 Volume 2: Technical Specifications.

Rationale – For all measures, except for Call Answer Timeliness (CAT) and Call Abandonment (CAB), the source of the text is the Agency for Healthcare Research and Quality (AHRQ) citations of NCQA as of July 2008. These citations appear under the Brief Abstract on the Web site of the National Quality Measures Clearinghouse, http://www.qualitymeasures.ahrq.gov/. For CAT and CAB the rationale was adapted from HEDIS 2004 Vol. 2: Technical Specifications, Appendix 2.

Summary of Changes for HEDIS 2008 – The source of the text, is the HEDIS 2009 Volume 2: Technical Specifications, incorporating additional changes published in the HEDIS 2009 Volume 2: “October” Technical Update.



V. Measure-Specific Findings Children’s Prevention and Screening Childhood Immunization Status (CIS) Description: The percentage of children two years of age who had four diphtheria, tetanus and acellular pertussis (DTaP), three polio (IPV), one measles, mumps and rubella (MMR), two H influenza type B (Hib), three hepatitis B, one chicken pox (VZV), and four pneumococcal conjugate vaccines by their second birthday. The measure calculates a rate for each vaccine and two separate combination rates.

Rationale: A basic method for prevention of serious illness is immunization. Childhood immunizations help prevent serious illnesses such as polio, tetanus and hepatitis. Vaccines are a proven way to help a child stay healthy and avoid the potentially harmful effects of childhood diseases like mumps and measles. Even preventing "mild" diseases saves hundreds of lost school days and work days, and millions of dollars.

Immunizations are the safest, most effective way to protect children from a variety of potentially serious childhood diseases. It is widely agreed that if immunization practices were to cease, most infectious diseases currently prevented by vaccinations would reemerge as serious health threats. The importance of vaccines is shown by the reappearance of diseases when immunization coverage drops. Despite established guidelines, well-known benefits of vaccination and high coverage, many children still do not receive their recommended immunizations. In 2007, almost one quarter of children age two to three lacked one or more recommended vaccinations.

Summary of Changes to HEDIS 2009: • Revised the required number of doses for the Hib vaccine, per ACIP recommendations

to defer the third Hib booster during vaccine shortage. • Deleted ICD-9-CM Procedure code 99.37 from Table CIS-A. Vaccine for acellular

pertussis antigen only is no longer produced. • Clarified medical record review requirements for immunizations documented using a

generic header of DTaP/DTP/DT. • Table CIS-A, deleted CPT codes 90702, 90703, 90719 and delete ICD-9-CM Procedure

codes 99.36, 99.38. Rationale: Because the member needs four DTaP immunizations for numerator compliance and because the vaccine for acellular pertussis antigen only is no longer produced, these codes cannot be used to demonstrate numerator compliance.

On the next page, tables show results for Combination 2 and Combination 3.



Childhood Immunization Status (CIS) – Combination 2 (DTaP/DT, IPV, MMR, Hib, Hepatitis B, VZV)

2005 2006 2007 2008 2009 ACC 80% 88% 88% 89.8% 82.1%

DIA NA 74% 68.1% 73.0%

JMS 76% 77% 75% 85.0% 87.1%

MPC 66% 70% 71% 72.2% 74.7%

MSFC 73% 74% 81% 84.7% 89.2%

PP 76% 80% 82% 86.5% 82.1%

UHC 65% 71% 73% 78.0% 84.8%

MARR 73% 77% 78% 80.6% 81.9%

NHM 63% 70% 73.3% 72.3%

Childhood Immunization Status (CIS) – Combination 3 (DTaP/DT, IPV, MMR, Hib, Hepatitis B, VZV, pneumococcal conjugate)

2005 2006 2007 2008 2009 ACC 72% 75% 81.0% 74.6%

DIA NA 66% 59.9% 69.4%

JMS 63% 74% 82.7% 80.6%

MPC 44% 62% 67.8% 70.1%

MSFC 44% 69% 78.1% 87.8%

PP 45% 72% 77.4% 77.4%

UHC 38% 60% 72.2% 78.7%

MARR 51% 68% 74.1% 76.9%

NHH 43% 60.6% 65.6%



Well-Child Visits in the First 15 Months of Life (W15) Description: The percentage of members who turned 15 months old during the measurement year and who had the following number of well-child visits with a PCP during their first 15 months of life: no well-child visits; one, two, three, four, five, six-or-more well-child visits.

Rationale: This measure looks at the adequacy of well-child care for infants. Regular check-ups are one of the best ways to detect physical, developmental, behavioral and emotional problems. They also provide an opportunity for the clinician to offer guidance and counseling to the parents.

These visits are of particular importance during the first year of life, when an infant undergoes substantial changes in abilities, physical growth, motor skills, hand-eye coordination and social and emotional growth. The American Academy of Pediatrics (AAP) recommends six well-child visits in the first year of life: the first within the first month of life, and then at around 2, 4, 6, 9, and 12 months of age.

Summary of Changes to HEDIS 2009 • Removed two data elements from Table W15-1/2: Number of administrative and

medical records excluded. • Eligible Population – Continuous Enrollment: replaced the last sentence with the

following: For example, a child born on January 9, 2007, and included in the rate of “six or more well-child visits” must have had six well-child visits by April 8, 2008.

Well-Child Visits in the First 15 months of Life (W15) – Zero visits*

2005 2006 2007 2008 2009 ACC 1% 1% 1% 1.1% 2.4% DIA 10% 7% 3.1% 2.6% JMS 6% 4% 3% 5.3% 2.6% MPC 4% 2% 1% 1.1% 0.7%

MSFC 2% 1% 2% 1.8% 1.1% PP 2% 2% 1% 0.7% 1.5%

UHC 0% 2% 2% 1.7% 1.8%

MARR 2% 3% 2% 2.1% 1.8% NHM 6% 5% 3.8% 5.6%

* A lower rate indicates better performance.

Well-Child Visits in the First 15 months of Life (W15) – DHMH Five plus six-or-more visits rates (additive)

2005 2006 2007 2008 2009 ACC 85% 93% 97% 85.4% 83.0% DIA 65% 71% 70.7% 77.1% JMS 76% 81% 94% 82.0% 81.8% MPC 81% 85% 83% 87.1% 87.3%

MSFC 83% 81% 78% 82.3% 81.0% PP 84% 83% 86% 81.3% 86.4%

UHC 79% 84% 87% 86.2% 86.0%

MARR 81% 82% 85% 82.1% 83.2%

NHM 64% 68% 72.9% 70.2%



Well-Child Visits in the Third, Fourth, Fifth, and Sixth Years of Life (W34) Description: The percentage of members 3–6 years of age who received one or more well-child visits with a PCP during the measurement year.

Rationale: This measure looks at the use of routine check-ups by preschool and early school-age children. Well-child visits during the preschool and early school years are particularly important. A child can be helped through early detection of vision, speech and language problems. Intervention can improve communication skills and avoid or reduce language and learning problems. The American Academy of Pediatrics (AAP) recommends annual well-child visits for 2 to 6 year-olds.

Summary of Changes to HEDIS 2009 Removed two data elements from Table W34-1/2: Number of administrative and medical records excluded. Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life (W34)

2005 2006 2007 2008 2009 ACC 79% 80% 80% 77.5% 74.2% DIA 49% 69% 66.4% 70.0%

JMS 79% 84% 88% 89.1% 89.9%

MPC 68% 70% 76% 79.1% 73.1%

MSFC 75% 66% 74% 74.1% 79.4%

PP 71% 70% 73% 77.4% 75.3%

UHC 68% 70% 80% 76.3% 75.4%

MARR 73% 70% 77% 77.1% 76.8%

NHM 62% 63% 66.8% 65.3 %



Adolescent Well-Care Visits (AWC) Description: The percentage of enrolled members 12–21 years of age who had at least one comprehensive well-care visit with a PCP or an OB/GYN practitioner during the measurement year.

Rationale: This measure looks at the use of regular check-ups by adolescents. Adolescents benefit from an annual preventive health care visit that addresses the physical, emotional and social aspects of their health.

Adolescence is a time of transition between childhood and adult life and is accompanied by dramatic changes. Accidents, homicide and suicide are the leading causes of adolescent deaths. Sexually transmitted diseases, substance abuse, pregnancy and antisocial behavior are important causes of, or result from, physical, emotional and social adolescent problems.

The American Medical Association's (AMA) Guidelines for Adolescent Preventive Services, the federal government's Bright Futures program and the American Academy of Pediatrics' (AAP) guidelines all recommend comprehensive annual check-ups for adolescents.

Summary of Changes to HEDIS 2009 Removed two data elements from Table AWC-1/2: Number of administrative and medical records excluded. Adolescent Well-Care Visits (AWC)

2005 2006 2007 2008 2009 ACC 57% 58% 57% 50.3% 54.1%

DIA 35% 50% 44.6% 49.7%

JMS 59% 72% 76% 73.3% 76.1%

MPC 48% 54% 60% 51.3% 49.5%

MSFC 55% 49% 59% 45.7% 52.8%

PP 46% 48% 54% 52.6% 53.4% UHC 50% 50% 59% 52.5% 47.3%

MARR 52% 52% 59% 52.9% 54.7%

NHM 39% 41% 43.7% 42.0%



Respiratory Conditions Appropriate Testing for Children with Pharyngitis (CWP) Description: The percentage of children 2-18 years of age who were diagnosed with pharyngitis, dispensed an antibiotic, and received a group A streptococcus (strep) test for the episode.

Rationale: Pharyngitis is the only condition among upper respiratory infections (URIs) whose diagnosis can easily be objectively validated through administrative and laboratory data, and it can serve as an important indicator of appropriate antibiotic use among all respiratory tract infections. Overuse of antibiotics has been directly linked to the prevalence of antibiotic resistance in the community; promoting judicious use of antibiotics is important to reducing levels of antibiotic resistance. Pediatric clinical practice guidelines recommend that only children with diagnosed group A streptococcus (strep) pharyngitis based on appropriate lab tests be treated with antibiotics. A strep test (rapid assay or throat culture) is the definitive test of group A strep pharyngitis. Excess use of antibiototics is highly prevalent for pharyngitis; about 35 percent of the total nine million antibiotics prescribed for pharyngitis in 1998 were estimated to be in excess.

Summary of Changes to HEDIS 2009 • Deleted CPT code 99499 from Table CWP-B. • Table CWP-D: Add LOINC code 49610-9. Delete LOINC code 11475-1.

Appropriate Testing for Children with Pharyngitis (CWP)

2005 2006 2007 2008 2009 ACC 68% 67.8% 66.4%

DIA 54% 47.9% 69.4%

JMS 73% 50.0% 67.3%

MPC 71% 74.8% 75.6%

MSFC 54% 75.8% 78.9%

PP 76% 78.2% 72.0% UHC 65% 67.4% 69.8%

MARR 66% 66.0% 71.4%

NHM 55.7% 58.2%



Appropriate Treatment for Children with Upper Respiratory Infection (URI) Description The percentage of children 3 months–18 years of age who were given a diagnosis of upper respiratory infection (URI) and were not dispensed an antibiotic prescription.

Rationale The common cold (upper respiratory infection [URI]) is a frequent reason for children visiting the doctor's office. Though existing clinical guidelines do not support the use of antibiotics for the common cold, physicians often prescribe them for this ailment. Pediatric clinical practice guidelines do not recommend antibiotics for a majority of upper respiratory tract infections due to viral etiology of these infections, including the common cold.

A performance measure of antibiotic use for URI sheds light on the prevalence of inappropriate antibiotic prescribing in clinical practice and raises awareness of the importance of reducing inappropriate antibiotic use to combat antibiotic resistance in the community.

Summary of Changes to HEDIS 2009 Deleted CPT code 99499 from Table URI-B.

Appropriate Treatment for Children with Upper Respiratory Infection (URI)

2005 2006 2007 2008 2009 ACC 86% 87.1% 85.0%

DIA 87% 82.9% 82.9% JMS 82% 87.3% 95.5%

MPC 83% 85.1% 84.0%

MSFC 85% 86.2% 86.3%

PP 94% 96.6% 84.4%

UHC 79% 80.6% 80.6%

MARR 85% 86.5% 85.5%

NHM 83.3% 84.1%



Use of Appropriate Medications for People with Asthma (ASM) Description: The percentage of members 5–56 years of age during the measurement year who were identified as having persistent asthma and who were appropriately prescribed medication during the measurement year.

Rationale: Asthma is one of the nation's most common and costly diseases. More than 30 million Americans, including almost 9 million children, will suffer from asthma at some point in their life. Asthma medications reduce underlying airway inflammation and relieve or prevent airway narrowing. Many asthma-related hospitalizations, emergency room visits, and missed work and school days can be avoided if patients' medications are managed appropriately.

Summary of Changes to HEDIS 2009 • Clarified dispensing event and inhaler dispensing event criteria. • Clarified in step 2 that a member prescribed a leukotriene modifier only needs at least

one diagnosis of asthma in the same year as the leukotriene modifier dispensing event. • Deleted CPT code 99499 from Table ASM-B. • Definitions – Dispensing Event: Add the following sentence to the end of the

paragraph: For two different prescriptions dispensed on the same day, sum the days’ supply to determine the number of dispensing events.

Use of Appropriate Medications for People with Asthma (ASM) – Age 5-9 years

2005 2006 2007 2008 2009 ACC 88% 88% 91.7% 90.0%

DIA NA NA NA NA

JMS NA NA NA NA

MPC 90% 91% 90.5% 91.5%

MSFC 91% 92% 91.5% 94.0%

PP 88% 89% 87.8% 91.9% UHC 92% 92% 92.0% 91.8%

MARR 90% 90% 90.7% 91.8%

NHM 88% 89.6% 89.3%



Use of Appropriate Medications for People with Asthma (ASM) – Age 10-17 years

2005 2006 2007 2008 2009 ACC 88% 89% 88.4% 88.7%

DIA NA NA NA NA

JMS 79% 77% 83.3% 72.5% MPC 89% 89% 89.0% 88.7%

MSFC 85% 90% 92.0% 93.4%

PP 86% 88% 85.2% 88.2%

UHC 90% 89% 90.3% 89.8%

MARR 86% 87% 88.1% 86.9%

NHM 86% 87.0% 86.9% Use of Appropriate Medications for People with Asthma (ASM) – Age 18-56 years

2005 2006 2007 2008 2009 ACC 87% 87% 87.9% 86.0%

DIA NA NA NA 92.3%

JMS 91% 85% 94.0% 91.7%

MPC 75% 85% 86.5% 84.0% MSFC 91% 92% 85.1% 92.9%

PP 76% 76% 78.7% 88.8%

UHC 86% 86% 86.0% 88.6%

MARR 84% 85% 86.4% 89.2%

NHM 83% 84.7% 84.5% Use of Appropriate Medications for People with Asthma (ASM) – Total rate

2005 2006 2007 2008 2009 ACC 87% 88% 89.6% 88.6%

DIA NA NA NA 91.6%

JMS 85% 83% 91.6% 87.3%

MPC 84% 88% 88.7% 87.9%

MSFC 89% 91% 89.5% 93.4%

PP 84% 86% 85.0% 89.5%

UHC 89% 89% 89.6% 90.1%

MARR 87% 88% 89.0% 89.8%

NHM 86% 87.1% 86.9%



Member Access Children and Adolescents’ Access to Primary Care Practitioners (CAP) Description: The percentage of members 12 months–19 years of age who had a visit with a primary care practitioner (PCP): • Children 12–24 months and 25 months–6 years of age who had a visit with a PCP

during the measurement year • Children 7–11 years and adolescents 12–19 years of age who had a visit with a PCP

during the measurement year or the year prior to the measurement year

Rationale: While the access to primary care has been shown to correlate with reduced hospital use while preserving quality (Bindham 1995, Bodenheimer 2005), this measure does not explicitly measure a member's access to primary care. However, studies show that inappropriate care and overuse of new technologies can be reduced through shared decision-making between well-informed physicians and patients. Physicians have a central role to play in fostering these quality-enhancing strategies that can help to slow the growth of health care expenditures (Bodenheimer 2005).

Continued rising health care costs in the U.S. affect all levels of the health care delivery system. Encouraging and making available access to primary care services is one potential strategy to lower hospital utilization while maintaining the quality of care delivered. Studies show that access to primary care is correlated with reduced hospital use while preserving quality (Bodenheimer 2005, Bindham 1995).

Summary of Changes to HEDIS 2009: No changes to this measure.

Children and Adolescents’ Access to Primary Care Practitioners (CAP) – Age 12-24 months

2005 2006 2007 2008 2009 ACC 97% 96.7% 97.4%

DIA 90% 92.2% 91.8%

JMS 91% 91.7% 88.3%

MPC 96% 96.5% 96.6%

MSFC 97% 96.9% 96.8%

PP 95% 94.2% 97.8%

UHC 95% 95.8% 96.3%

MARR 94% 94.9% 95.0%

NHM 94.1% 93.4%



Children and Adolescents’ Access to Primary Care Practitioners (CAP) – Age 25 months to 6 years

2005 2006 2007 2008 2009 ACC 91% 91.1% 91.7%

DIA 82% 82.9% 85.5%

JMS 89% 88.4% 89.5% MPC 91% 90.0% 91.1%

MSFC 89% 89.8% 91.6%

PP 85% 86.5% 91.7%

UHC 89% 90.8% 92.2%

MARR 88% 88.5% 90.4%

NHM 84.9% 84.3% Children and Adolescents’ Access to Primary Care Practitioners (CAP) – Age 7-11 years

2005 2006 2007 2008 2009 ACC 92% 92.3% 92.6%

DIA 81% 82.7% 84.6%

JMS 90% 89.3% 93.7% MPC 92% 91.2% 91.6%

MSFC 92% 92.2% 92.2%

PP 87% 88.0% 92.9%

UHC 90% 92.1% 92.2%

MARR 89% 89.7% 91.4%

NHM 86.0% 85.8% Children and Adolescents’ Access to Primary Care Practitioners (CAP) – Age 12-19 years

2005 2006 2007 2008 2009 ACC 89% 88.4% 87.3%

DIA 80% 84.9% 81.0%

JMS 92% 92.8% 91.9%

MPC 88% 89.2% 88.4% MSFC 89% 90.0% 88.7%

PP 83% 84.0% 89.0%

UHC 86% 88.6% 87.6%

MARR 87% 88.3% 87.7%

NHM 83.2% 82.6%



Adults’ Access to Preventive/Ambulatory Health Services (AAP) Description: The percentage of members 20 years of age and older who had an ambulatory or preventive care visit during the measurement year. The organization reports three age stratifications (20-44 years, 45-65 years, 65 years and older) and a total rate.

Rationale: While access to primary care has been shown to correlate with reduced hospital use while preserving quality (Bodenheimer, 2005, Bindham, 1995), this measure does not explicitly measure a member's access to primary care. However, studies show that inappropriate care and overuse of new technologies can be reduced through shared decision-making between well-informed physicians and patients. Physicians have a central role to play in fostering these quality-enhancing strategies that can help to slow the growth of health care expenditures (Bodenheimer, 2005).

Continued rising health care costs in the U.S. affect all levels of the health care delivery system. Encouraging and making available access to primary and preventive care services is one potential strategy to lower hospital utilization while maintaining the quality of care delivered. Studies show that access to primary care is correlated with reduced hospital use while preserving quality (Bodenheimer, 2005, Bindham, 1995).

Summary of Changes to HEDIS 2009 • Deleted CPT codes 99301–99303, 99311–99313, 99321–99323, 99331-99333 from

Table AAP-A. • Added CPT codes 99315, 99316 to Table AAP-A. • Consolidated rows and descriptions in Table AAP-A. • Eligible Population – Ages: Add “and a total rate” at the end of the second sentence.

Add a fourth bullet and the following sentence below the bullets “• Total. The total rate is the sum of the three numerators divided by the sum of the three denominators.”

• Data Elements for Reporting: Replace all references of “For each age stratification” with “For each age stratification and total.”

Adults’ Access to Preventive/Ambulatory Health Services (AAP) – Age 20-44 years

2005 2006 2007 2008 2009 2009 PAC

ACC 77% 76.7% 77.3%

DIA 72% 71.3% 75.2%

JMS 74% 76.1% 77.2% 72.0% MPC 77% 74.4% 79.0% 62.5%

MSFC 76% 74.8% 79.2%

PP 77% 77.0% 79.3%

UHC 72% 73.8% 75.7% 60.9%

MARR 75% 74.9% 77.6%

NHM 78.2% 76.8%



Adults’ Access to Preventive/Ambulatory Health Services (AAP) – Age 45-64 years

2005 2006 2007 2008 2009 2009 PAC

ACC 84% 83.8% 83.9%

DIA 76% 78.6% 78.6%

JMS 87% 85.8% 86.9% 80.9%

MPC 85% 85.0% 87.5% 73.1%

MSFC 83% 84.1% 85.5%

PP 87% 87.1% 87.5% UHC 84% 85.3% 85.6% 69.4%

MARR 84% 84.2% 85.1%

NHM 83.1% 82.4%



Women’s Health Breast Cancer Screening (BCS) Description: The percentage of women 40–69 years of age who had a mammogram to screen for breast cancer.

Rationale: Breast cancer is the second most common type of cancer among American women, with approximately 178,000 new cases reported each year. It is most common in women over 50. Women whose breast cancer is detected early have more treatment choices and better chances for survival. Mammography screening has been shown to reduce mortality by 20% to 30% among women 40 and older.

The U.S. Preventive Services Task Force, the American Academy of Family Physicians and the American College of Preventive Medicine recommend mammograms as the most effective method for detecting breast cancer when it is most treatable. When high quality equipment is used and well trained radiologists read the x-rays, 85% to 90% of cancers are detectable.

Summary of Changes to HEDIS 2009 • Removed age stratifications. • Added HCPCS codes G0204, G0206 to Table BCS-A. • Added UB Revenue code 0401 to Table BCS-A. • Deleted CPT code 76083 from Table BCS-A.

Breast Cancer Screening (BCS)

2005 2006 2007 2008 2009 2009 PAC

ACC 44% 42.0% 41.3%

DIA 27% 32.8% 39.9%

JMS 56% 64.3% 64.4% 44.6%

MPC 46% 45.6% 46.1% 28.8%

MSFC 49% 50.9% 57.6% PP 42% 42.3% 42.2%

UHC 46% 51.4% 51.2% 23.0%

MARR 44% 47.0% 49.0%

NHM 49.1% 50.0%



Cervical Cancer Screening (CCS)

Description: The percentage of women 21–64 years of age who received one or more Pap tests to screen for cervical cancer.

Rationale: Cervical cancer is the second most common cancer worldwide and the third leading cause of cancer-related death. An estimated 11,000 new cases of cervical cancer will be diagnosed in 2008, resulting in more than 3,800 deaths. Most of these deaths could have been avoided with timely and effective screening and treatment. Cervical cancer is a preventable and treatable cancer, as precancerous lesions can usually be found through regular screening.

Cervical cancer can be detected in its early stages by regular screening using a Pap test. A number of organizations, including the American College of Obstetricians and Gynecologists, the American Medical Association and the American Cancer Society, recommend Pap testing every one to three years for all women who have been sexually active or who are over 21 years of age.

Summary of Changes to HEDIS 2009 • Added LOINC code 47528-5 to Table CCS-A. • Added CPT codes 58570–58573 to Table CCS-B. • Table CCS-A: Delete HCPCS code G0101.

Cervical Cancer Screening (CCS)

2005 2006 2007 2008 2009 2009 PAC

ACC 71% 61.4% 67.9%

DIA 44% 48.0% 62.7%

JMS 78% 73.8% 78.0% 54.1%

MPC 62% 64.1% 66.3% 33.5%

MSFC 58% 64.7% 66.4%

PP 63% 65.6% 63.0%

UHC 61% 64.8% 66.1% 29.6%

MARR 62% 63.2% 67.2%

NHM 65.7% 64.8%



Chlamydia Screening in Women (CHL) Description: The percentage of women 16–24 years of age who were identified as sexually active and who had at least one test for Chlamydia during the measurement year. Rationale: Chlamydia trachomatis is the most common sexually transmitted disease (STD) in the United States (U.S.). The Centers for Disease Control and Prevention (CDC) estimate that approximately three million people are infected with chlamydia each year. Risk factors associated with becoming infected with chlamydia are the same as risks for contracting other STDs (e.g., multiple sex partners). Chlamydia is more prevalent among adolescent (15 to 19) and young adult (20 to 24) women. Over two million Americans 14 to 39 years of age have chlamydia. Chlamydia is called a "silent" sexually transmitted disease; three in four infected women and half of all infected men do not realize they have the infection; there are no symptoms until one to three weeks after infection occurs. Left untreated, chlamydia can cause permanent damage to a woman's fallopian tubes, uterus and surrounding tissue. Other effects of chlamydia include urethritis, cervicitis, pelvic inflammatory disease (PID), infertility, ectopic pregnancy or chronic pelvic pain. Women that are pregnant and have a chlamydial infection are at higher risk for miscarriage, a premature rupture of membranes, preterm labor, low birth weight and infant mortality. Twenty to twenty-five percent of newborns exposed to their mother's chlamydia develop chlamydial conjunctivitis. Chlamydia screening is one of the most effective and underutilized screening services. Screening for chlamydia is essential because the majority of women who have the condition do not experience symptoms. The main objective of chlamydia screening is to prevent PID, infertility and ectopic pregnancy, all of which have very high rates of occurrence among women with untreated chlamydia infection. The specifications for this measure are consistent with current clinical guidelines, such as those of the U.S. Preventive Services Task Force. Summary of Changes to HEDIS 2009 • Decreased upper age limit to 24 years. • Added ICD-9-CM Diagnosis code V73.81 to Table CHL-B. • Deleted ICD-9-CM Diagnosis code 078.10, 078.19 from Table CHL-B. • Added LOINC codes 47527-7, 47528-5 to Table CHL-B. • Table CHL-C: Add LOINC codes 44806-8, 44807-6, 45067-6, 45068-4, 45069-2,

45070-0, 45074-2, 45076-7, 45078-3, 45080-9, 45084-1, 45091-6, 45095-7, 45098-1, 45100-5, 47211-8, 47212-6, 49096-1, 50387-0.

• Table CHL-C: Delete LOINC codes 16602-5, 20993-2.

Chlamydia Screening in Women (CHL) – Age 16-20 years

2005 2006 2007 2008 2009 ACC 60% 55.6% 58.3%

DIA 45% 52.2% 46.4%

JMS 69% 79.5% 81.0% MPC 60% 57.7% 58.6%

MSFC 52% 56.6% 52.0%

PP 57% 58.0% 58.1%

UHC 49% 46.0% 50.3%

MARR 56% 58.0% 57.8%

NHM 50.5% 48.7%



Chlamydia Screening in Women (CHL) – Age 21-24 years

2005 2006 2007* 2008* 2009 ACC 70% 66.0% 68.7%

DIA 57% 65.2% 56.8%

JMS 70% 70.9% 73.9%

MPC 72% 67.7% 68.2% MSFC 56% 64.3% 63.4%

PP 67% 64.7% 63.6%

UHC 58% 55.8% 59.3%

MARR 64% 64.9% 64.8%

NHM 55.0% 54.1%

*Rates for 2008 and the prior year were for ages 21-25.

Chlamydia Screening in Women (CHL) – Total (16-24) years

2005 2006 2007* 2008* 2009 ACC 63% 59.2% 61.3%

DIA 51% 57.8% 50.2%

JMS 69% 76.6% 78.7%

MPC 63% 60.5% 61.1%

MSFC 53% 58.9% 55.1%

PP 60% 59.7% 59.4%

UHC 52% 48.6% 52.5%

MARR 59% 60.2% 59.8% NHM 52.4% 50.8%

*Rates for 2008 and the prior year were for ages 16-25.



Prenatal and Postpartum Care Prenatal and Postpartum Care (PPC) Description: The percentage of deliveries of live births between November 6 of the year prior to the measurement year and November 5 of the measurement year. For these women, the measure assesses the following facets of prenatal and postpartum care:

Timeliness of Prenatal Care: The percentage of deliveries that received a prenatal care visit as a member of the organization in the first trimester or within 42 days of enrollment in the organization.

Postpartum Care: The percentage of deliveries that had a postpartum visit on or between 21 and 56 days after delivery.

Rationale:

Timeliness of Prenatal Care: Preventive medicine is fundamental to prenatal care. Healthy diet, counseling, vitamin supplements, identification of maternal risk factors and health promotion all need to occur early in pregnancy to have a maximum impact on outcome. Poor outcome includes spontaneous abortion, low-birth-weight babies, large-for-gestational-age babies and neonatal infection. Early prenatal care is also an essential part of helping a pregnant woman prepare to become a mother. Ideally, a pregnant woman will have her first prenatal visit during the first trimester of pregnancy. Some women enroll in a health plan at a later stage of pregnancy; in this case, it is essential for the health plan to begin providing prenatal care as quickly as possible.

Postpartum Care: The American College of Obstetricians and Gynecologists recommends that women see their health care provider at least once between four and six weeks after giving birth. The first postpartum visit should include a physical examination and an opportunity for the health care practitioner to answer parents' questions and give family planning guidance and counseling on nutrition.

Summary of Changes to HEDIS 2009 • Deleted DRGs from Table PPC-B. • Added LOINC codes 47527-7, 47528-5 to Table PPC-E. • Deleted CPT codes 88144, 88145 from Table PPC-E. • Added examples of medical record documentation that meet criteria for notation of

postpartum care. • Clarified that two rates are reported (Table PPC-1/2). • Removed two data elements from Table PPC-1/2: Number of administrative and

medical records excluded. • Table PPC-C—Decision Rule 2 and Decision Rule 3: Perform the following for both

Decision Rule 2 and Decision Rule 3. Add LOINC codes 47307-4, 45326-6, 47363-7, 47430-4, 49539-0, 52976-8, 52984-2 to the Cytomegalovirus row. Add LOINC codes 43180-9, 44008-1, 44480-2, 44494-3, 44507-2, 45210-2, 47230-8, 48784-3, 49848-5, 50758-2, 51915-7, 51916-5, 52977-6, 52981-8, 53377-8, 53560-9 to the Herpes simplex row. Add LOINC codes 40667-8, 43810-1, 49107-6, 50694-9, 51931-4, 52986-7 to all Rubella rows. Add LOINC codes 40697-5, 41123-1, 41124-9, 47389-2, 47390-0 to the Toxoplasma row. Delete LOINC codes 15396-5, 23484-9, 24398-0, 24399-8, 33337-7, 40676-9 from the Toxoplasma row.



Prenatal and Postpartum Care (PPC) – Timeliness of Prenatal Care

2005 2006 2007 2008 2009 ACC 94% 94% 98% 90.9% 90.9%

DIA 68% 89% 85.0% 87.3%

JMS 83% 83% 88% 89.7% 88.4%

MPC 86% 85% 87% 84.0% 87.0%

MSFC 90% 90% 90% 90.0% 87.2%

PP 82% 82% 87% 91.1% 91.4%

UHC 87% 90% 88% 91.7% 89.7%

MARR 87% 85% 89% 88.9% 88.8%

NHM 78% 79% 81.2% 81.4%

Prenatal and Postpartum Care (PPC) – Postpartum Care

2005 2006 2007 2008 2009 ACC 74% 84% 85% 61.9% 64.3%

DIA 39% 52% 52.9% 52.8% JMS 55% 51% 72% 68.2% 72.6%

MPC 61% 62% 60% 60.3% 62.1%

MSFC 64% 55% 55% 67.4% 71.9%

PP 61% 63% 63% 64.6% 63.5%

UHC 63% 61% 64% 64.3% 67.6%

MARR 63% 59% 64% 62.8% 65.0%

NHM 56% 57% 59.1% 58.7%



Frequency of Ongoing Prenatal Care (FPC) Description: The percentage of Medicaid deliveries between November 6 of the year prior to the measurement year and November 5 of the measurement year where the mother received the following number of expected prenatal visits:

< 21 percent of expected visits 21 percent–40 percent of expected visits 41 percent–60 percent of expected visits 61 percent–80 percent of expected visits ≥ 81 percent of expected visits

This measure uses the same denominator as the Prenatal and Postpartum Care measure.

Rationale This measure looks at the use of prenatal care services. It tracks Medicaid-enrolled women who had live births during the past year to determine the percentage of recommended prenatal visits they had.

Complications can arise at any time during pregnancy. For that reason, continued monitoring throughout pregnancy is necessary. Frequency and adequacy of ongoing prenatal visits are important factors in minimizing pregnancy problems.

The American College of Obstetricians and Gynecologists recommends that prenatal care begin as early as possible in the first trimester of pregnancy. Visits should follow a schedule: • Every 4 weeks for the first 28 weeks of pregnancy • Every 2 to 3 weeks for the next 7 weeks • Weekly thereafter until delivery

Summary of Changes to HEDIS 2009 Removed two data elements from Table FPC-1: Number of administrative and medical records excluded. Frequency of Ongoing Prenatal Care (FPC) – Less than 21% of expected visits

2005 2006 2007 2008 2009 ACC 2% 1% 1% 1.3% 2.4%

DIA 19% 8% 6.2% 7.1%

JMS 6% 6% 4% 1.5% 2.3%

MPC 4% 4% 7% 6.2% 3.3%

MSFC 2% 4% 6% 3.2% 2.7%

PP 5% 1% 6% 3.4% 4.3%

UHC 9% 7% 5% 6.0% 4.5%

MARR 5% 6% 5% 4.0% 3.8%

NHM 19% 17% 13.5% 12.5%



Frequency of Ongoing Prenatal Care (FPC) – Greater than or equal to 81% of expected visits

2005 2006 2007 2008 2009 ACC 78% 88% 87% 75.7% 74.3%

DIA 48% 61% 61.4% 62.2%

JMS 66% 79% 80% 84.6% 81.9%

MPC 70% 78% 62% 78.7% 71.6%

MSFC 70% 81% 82% 85.9% 92.1%

PP 44% 60% 70% 75.3% 76.6% UHC 66% 75% 72% 75.3% 78.2%

MARR 66% 73% 73% 76.7% 76.7%

NHM 51% 56% 58.6% 59.3%



Diabetes Care Comprehensive Diabetes Care (CDC) Description: The percentage of members 18–75 years of age with diabetes (type 1 and type 2) who had each of the following:

Hemoglobin A1c (HbA1c) testing HbA1c poor control (>9.0%) HbA1c control (<8.0%) Eye exam (retinal) performed LDL-C screening LDL-C control (<100 mg/dL) Medical attention for nephropathy Blood pressure control (<130/80 mm Hg) Blood pressure control (<140/90 mm Hg)

Rationale: Diabetes is a group of diseases characterized by high blood glucose levels caused by the body's inability to correctly produce or use the hormone insulin. It is one of the leading causes of death and disability in the U.S. More than 20 million Americans live with diabetes today. One-third of people with diabetes are not diagnosed. Much of the burden of illness and cost of diabetes treatment is attributed to potentially preventable long-term complications including heart disease, blindness, kidney disease and stroke. Timely screening and treatment can significantly reduce the disease burden.

Summary of Changes to HEDIS 2009

Eligible population for all indicators: • Added amylin analogs category to Table CDC-A. • Deleted CPT code 99499 from Table CDC-C.

HbA1c control (<8.0%): First-year indicator. Specifications published in the HEDIS 2009 Volume 2 Technical Update

Eye exam (retinal) performed: • Removed the requirement that HCPCS S0625 (Table CDC-G) be billed by an

optometrist or ophthalmologist. • Added CPT codes 67041-67043, 67113 to Table CDC-G. • Clarified the use of CPT Category II code 3072F in Table CDC-G.

LDL-C screening: • Deleted CPT codes 83715, 83716 from Table CDC-H.

Nephropathy: • Deleted DRGs from Tables CDC-B, CDC-K. • Added UB Type of Bill code 72x to Table CDC-K. • Added POS code 65 to Table CDC-K. • Table CDC-J: Add LOINC codes 47558-2, 49023-5, 50561-0, 50949-7, 53121-0,

53525-2, 53530-2, 53531-0, 53532-8. • Table CDC-K: Add LOINC codes 50556-0, 50561-0, 50564-4 to the Urine

macroalbumin test row.



Comprehensive Diabetes (CDC) – Hemoglobin A1c (HBA1c)Testing

2005 2006 2007 2008 2009 2009 PAC

ACC 83% 88% 78% 73.2% 78.8% DIA 68% 64% 68.0% 67.8% JMS 84% 86% 85% 89.7% 90.7% 83.6% MPC 81% 76% 76% 78.4% 74.2% 77.4%

MSFC 79% 83% 84% 87.7% 85.1% PP 77% 85% 82% 78.3% 77.7%

UHC 75% 72% 74% 74.7% 71.0% 64.4%

MARR 80% 80% 78% 78.6% 77.9% NHM 75% 76% 78.0% 77.4%

Comprehensive Diabetes (CDC) – HbA1c Poor Control (>9.0%) *

2005 2006 2007 2008 2009 2009 PAC

ACC 44% 34% 45% 52.5% 49.6% DIA 52% 50% 52.6% 52.1% JMS 38% 39% 38% 32.6% 30.3% 39.0% MPC 51% 53% 61% 55.5% 57.9% 51.4%

MSFC 43% 40% 35% 38.2% 33.8% PP 52% 39% 47% 38.7% 47.3%

UHC 42% 43% 46% 50.9% 56.4% 83.3%

MARR 45% 43% 46% 45.9% 46.8% NHM 50% 49% 48.7% 47.7%


Comprehensive Diabetes (CDC) – HbA1c Control (< 8.0%)*

2005 2006 2007 2008 2009 2009 PAC

ACC 43.6% DIA 42.1% JMS 57.8% 49.2% MPC 36.4% 38.6%

MSFC 54.6% PP 45.8%

UHC 37.2% 13.1%

MARR 45.4% NHM*

* This is a first-year measure. There is no NHM from HEDIS 2008 reporting.



Comprehensive Diabetes (CDC) – Eye Exam (Retinal) Performed

2005 2006 2007 2008 2009 2009 PAC

ACC 50% 76% 73% 57.5% 50.1% DIA 10% 43% 43.3% 52.1% JMS 62% 74% 72% 75.3% 77.2% 48.0% MPC 41% 50% 54% 54.4% 65.8% 31.9%

MSFC 39% 66% 63% 66.2% 72.2% PP 40% 52% 55% 63.3% 54.6%

UHC 50% 55% 57% 58.2% 65.9% 25.6%

MARR 47% 55% 59% 59.7% 62.6% NHM 44% 47% 51.4% 50.1%

Comprehensive Diabetes (CDC) – LDL-C Screening

2005 2006 2007 2008 2009 2009 PAC

ACC 73% 72.7% 74.5% DIA 57% 64.9% 66.9% JMS 84% 90.3% 93.3% 88.7% MPC 76% 72.7% 73.9% 70.9%

MSFC 80% 82.8% 81.7% PP 72% 73.7% 73.9%

UHC 74% 71.8% 71.5% 59.5%

MARR 74% 75.6% 76.5% NHM 71.1% 70.9%

Comprehensive Diabetes (CDC) – LDL-C Control (<100 mg/dL)

2005 2006 2007 2008 2009 2009 PAC

ACC 37% 33.5% 34.9% DIA 20% 27.8% 28.1% JMS 53% 48.2% 47.2% 42.7% MPC 27% 28.6% 28.9% 31.2%

MSFC 43% 42.3% 43.8% PP 38% 37.5% 42.5%

UHC 36% 30.2% 29.2% 10.4%

MARR 36% 35.4% 36.4% NHM 30.6% 31.4%



Comprehensive Diabetes (CDC) – Medical Attention for Nephropathy

2005 2006 2007 2008 2009 2009 PAC

ACC 83% 80.3% 78.8% DIA 63% 75.3% 75.2% JMS 91% 95.9% 93.3% 86.5% MPC 79% 74.8% 75.8% 82.8%

MSFC 85% 87.4% 86.6% PP 77% 83.9% 78.3%

UHC 75% 77.6% 73.7% 70.1%

MARR 79% 82.2% 80.2% NHM 74.6% 74.4%

Comprehensive Diabetes (CDC) – Blood Pressure Control (<130/90 mm Hg)

2005 2006 2007 2008 2009 2009 PAC*

ACC 26% 31.1% 27.2% DIA 16% 25.8% 25.6% JMS 29% 25.9% 23.6% NR* MPC 26% 25.8% 25.6% 21.2%

MSFC 36% 31.0% 36.3% PP 45% 35.8% 33.6%

UHC 26% 26.0% 28.2% 0.0%*

MARR 29% 28.8% 28.6%

NHM 30.4% 29.6%

*calculated administratively; no administrative data


2005 2006 2007 2008 2009 2009 PAC

ACC 56% 56.8% 54.7% DIA 41% 40.2% 45.5% JMS 53% 52.1% 47.2% NR* MPC 45% 49.2% 51.2% 45.3%

MSFC 61% 63.3% 65.7% PP 66% 65.2% 58.8%

UHC 50% 55.7% 55.7% 0.0%*

MARR 53% 54.6% 54.1% NHM 30.4% 55.5%

*calculated administratively; no administrative data



Ambulatory Care (utilization) Ambulatory Care (AMB) Description: This measure summarizes utilization of ambulatory care in the following categories:

• Outpatient Visits • ED Visits • Ambulatory Surgery/Procedures • Observation Room Stays

Rationale: Outpatient visits include office visits or routine visits to hospital outpatient departments. Emergency rooms often deliver nonemergency care. An organization that promotes effective ambulatory treatment of patients should be able to keep the number of emergency room visits relatively low. Looking at inpatient surgery and ambulatory surgery together can help assess how much outpatient surgery is performed.

Summary of Changes to HEDIS 2009 • Deleted redundant wording from the measure specification; the language edits are not

intended to change the intent of the measure specification. • Deleted CPT codes 99301–99303, 99311–99313, 99321–99323, 99331–99333, 99354,

99355, 99499 from Table AMB-A. • Added CPT codes 99304–99310, 99315, 99316, 99318, 99324–99328, 99334–99337 to

Table AMB-A. • Consolidated rows and descriptions in Table AMB-A. • Deleted CPT codes 93534-93536 from Table AMB-C. • Converted exclusion criteria into table format.

Ambulatory Care (AMB) – Outpatient Visits

2005 2006 2007 2008 2009 ACC 374.0 DIA 330.5 JMS 364.2 MPC 375.2

MSFC 380.0 PP 382.2

UHC 365.1

MARR 367.3 NHM



Ambulatory Care (AMB) – Emergency Department

2005 2006 2007 2008 2009 ACC 60.3

DIA 88.0

JMS 78.8

MPC 71.8

MSFC 76.6

PP 62.4

UHC 59.3

MARR 71.0

NHM

Ambulatory Care (AMB) – Ambulatory Surgery

2005 2006 2007 2008 2009 ACC 6.5

DIA 13.5

JMS 14.0

MPC 9.0

MSFC 13.3

PP 10.8

UHC 9.1

MARR 10.9

NHM

Ambulatory Care (AMB) – Observation Room Stays

2005 2006 2007 2008 2009 ACC 2.0

DIA 1.8

JMS 2.4

MPC 1.5

MSFC 0.3

PP 3.7

UHC 1.4

MARR 1.9

NHM



Call Services Call Answer Timeliness (CAT) Rationale: Health care providers, organization members, and purchasers increasingly recognize the importance of customer service as a factor in patient satisfaction. The collected data will provide opportunities for organization comparisons, as well as quality improvement initiatives.

Description: The percentage of calls received by the organization’s Member Services call centers (during operating hours) during the measurement year that were answered by a live voice within 30 seconds.

Summary of Changes to HEDIS 2009 • Clarified reporting of calls that are sent directly to voicemail.

Call Answer Timeliness (CAT)

2005 2006 2007 2008 2009 ACC 47% 67% 52.0% 75.8% DIA 87% 90% 85.7% 91.4% JMS NR 85% 86.0% 89.9% MPC 75% 76% 74.5% 82.7%

MSFC 58% 86% 84.2% 94.3% PP NR* NR* NR* 68.2%

UHC 74% 60% 89.1% 81.5%

MARR 68% 77% 78.6% 83.4% NHM 74% 74.4% 79.4%

*This organization was unable to report the Call Answer Timeliness measure for HEDIS 2008 because its call system was not able to track calls answered within 30 seconds until August 2007.



Call Abandonment (CAB) Rationale: See Call Answer Timeliness Description: The percentage of calls received by the organization’s Member Services call centers (during operating hours) during the measurement year that were abandoned by the caller before being answered by a live voice. Lower rates represent better performance.

Summary of Changes to HEDIS 2009 Clarified reporting of calls that are sent directly to voicemail. Call Abandonment (CAB)*

2005 2006 2007 2008 2009 ACC 16% 10% 9.3% 3.6% DIA 1% 1% 1.1% 0.8% JMS NR 14% 3.9% 3.3% MPC 4% 3% 2.9% 2.0%

MSFC 5% 2% 2.2% 1.6% PP 9% NR 5.0% 4.2%

UHC 3% 8% 1.2% 3.1%

MARR 6% 6% 3.7% 2.7% NHM 5% 5.8% 5.5%




VI. HealthChoice and Primary Adult Care HEDIS 2009 Results General Observations HEDIS is a widely used and respected set of standardized quality indicators. But as with any measurement tool, it is important to understand proper uses and limitations. HEDIS results can be used as markers of care, but cannot be used, on their own, to draw conclusions about the quality of care. A comparison among organizations on the basis of HEDIS rates, alone, would not take into account population differences, such as age, health status, or catchment area (urban vs. rural). For example: Maryland Medicaid organizations are dissimilar in location served; two organizations operate statewide, four are regional, and one operates in Baltimore City and parts of Baltimore County. The effect of these geographic locations on HEDIS rates is unknown.

Trends in rates can indicate genuine improvement or could indicate something else, e.g., familiarity with HEDIS reporting or improved data systems. A decrease in rates could indicate care issues but also could indicate something else, e.g., population factors or subtle changes in specifications.

For HealthChoice organizations, there has been some “flattening of rates” across many HEDIS measures as reporting matures. However, there is also room for improvement by many of the HealthChoice organizations, particularly where the organization’s score does not at least meet or exceed the NHM. Measures where this occurs are: URI, CAP, BCS, CCS, CDC, CAB, and CAT.

Some changes in the 2009 MARR performance scores that deserve special attention are mentioned below:

Well-Child Visits in the First 15 months of Life (W15) – DHMH Five plus six-or-more visits rates (additive): The MARR increased from 82.1 to 83.2 largely attributable to marked increases in the scores by DIA (70.7 to 77.1) and PP (81.3 to 86.4).

Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life (W34): The MARR decreased from 77.1 to 76.8 largely attributable to decreases noted by ACC, MPC, PP, and UHC.

Adolescent Well-Care Visits (AWC): The MARR increased from 52.9 to 54.7 largely attributable to marked increases in the scores by ACC (50.3 to 54.1), DIA (44.6 to 49.7), JMS (73.3 to 76.1), and MSFC (45.7 to 52.8). The MARR would have increased more except for decreases noted in UHC and MPC.

Appropriate Testing for Children with Pharyngitis (CWP): The MARR had a marked increase from 66.0 to 71.4 largely attributable to significant increases posted by DIA (47.9 to 69.4) and JMS (50.0 to 67.3).

Use of Appropriate Medications for People with Asthma (ASM) – Age 18-56 years: The MARR increased from 86.4 to 89.2 largely attributable to significant increases recorded by MSFC (85.1 to 92.9) and PP (78.7 to 88.8).

Prenatal and Postpartum Care (PPC) – Postpartum Care: The MARR increased from 62.8 to 65.0 largely attributable to increases in the measure by ACC (61.9 to 64.3), JMS (68.2 to 72.6), MSFC (67.4 to 71.9), and UHC (64.3 to 67.6).

Comprehensive Diabetes (CDC) – Eye Exam (Retinal) Performed: The MARR increased from 59.7 to 62.6 largely attributable to increases recorded by DIA (43.3 to 52.1), MPC (54.4 to 65.8), MSFC (66.2 to 72.2), and UHC (58.2 to 65.9). A higher increase in the MARR would have occurred except for decreases recorded by ACC and PP.



Future considerations and recommendations The HEDIS 2009 audits continued to reflect a period of stability and continuity in terms of measures being reported. DHMH moved the Ambulatory Care measure to a public-reporting status after allowing two years for organizations to examine processes and identify any data issues. For 2009, two new administrative-only measures (IET and IAD) were added as testing measures. (Public reporting may be a consideration for the future.) Also new this year was the reporting of a limited set of HEDIS measures by three PAC organizations. (Please see the table, HEDIS Measures Reporting History in Section III for a measure-specific reporting history.)

Given what has been learned about HEDIS reporting within the Maryland Medicaid community, the following recommendations are provided:

• There are a number of reasons why organizations may want to explore expanded HEDIS reporting. Organizations should remain proactive in anticipating DHMH decisions to expand the set of required measures. Organizations seeking NCQA accreditation and have already increased the number of reported measures to match the set required for accreditation. With all organizations now contracting with an NCQA-certified software vendor, production of additional HEDIS measures can readily be achieved. These results can be highly useful for internal quality purposes, as well as for an expanded familiarity with HEDIS reporting. Organizations will have a good tool to determine where data anomalies or clinical/service issues are present.

• Internal and external drivers to promote improvement in HEDIS scores should be recognized and encouraged. As the HEDIS reporting has matured and organizations have become very familiar with the HEDIS reporting processes, they have been able to concentrate on the improvement of performance scores through clinical and service interventions, as well as through analyses of provider coding. The implementation of the DHMH Valued Based Purchasing initiative has serviced as an external factor encouraging a proactive approach to performance improvement among all organizations.

• It is recommended that all organizations continue to look at opportunities to enhance administrative scores in order to reduce medical record review burdens as well as to ensure that administrative rates reflect total service provision. All organizations used some type of administrative database to supplement existing clinical data, to varying degrees. Organizations should plan ahead to seek HEDIS auditor approval of supplemental databases by conferring with the auditor at the inception of any database development to ensure data is captured and can be validated according to HEDIS audit protocol.

• Publication of PAC performance scores may motivate all PAC organizations to allocate sufficient resources to use the hybrid method for HEDIS 2010. (Please refer the table in Section I., HEDIS Methodology, showing organization-specific use of the administrative or hybrid method, by measure.) HEDIS performance scores for PAC organizations fell below scores for the HealthChoice product at the same organization. For the CCS and CDC measure, this is primarily attributable to nonuse of the hybrid method.



HEDIS 2009 Reported Rates

The HealthChoice HEDIS 2009 results are displayed in Table A for the seven HealthChoice organizations. The table presents the audited results for each measure for the current and past two years and includes:

♣• Names of organizations submitting reportable results

♣• Maryland Average Reportable Rate (MARR) for all Maryland HealthChoice organizations that provided audited and reportable data

• National HEDIS Mean (NHM)

For a five-year history and for information concerning any specification changes over that period of time, please see the measure-specific findings in Section III of this report.

Formatted: Bullets and Numbering

Table A – HealthChoice Organization HEDIS® 2009 Measures – Reported Rates

ACC 2007

ACC 2008

ACC 2009

DIA 2007

DIA 2008

DIA 2009

JMS 2007

JMS 2008

JMS 2009

MPC 2007

MPC 2008

MPC 2009

MSFC 2007

MSFC 2008

MSFC 2009

PP 2007

PP 2008

PP 2009

UHC 2007

UHC 2008

UHC 2009

MARR 2009

NHM 2008

Children’s Prevention and Screening Childhood Immunization Status (CIS) – Combination 2 (DtaP/DT, IPV, MMR, HIB, Hepatitis B, VZV)

88% 89.8% 82.1% 74% 68.1% 73.0% 75% 85.0% 87.1% 71% 72.2% 74.7% 81% 84.7% 89.2% 82% 86.5% 82.1% 73% 78.0% 84.8% 81.9% 72.3%

Childhood Immunization Status (CIS) – Combination 3 (DtaP/DT, IPV, MMR, HIB, Hepatitis B, VZV, pneumococcal conjugate)

75% 81.0% 74.6% 66% 59.9% 69.4% 74% 82.7% 80.6% 62% 67.8% 70.1% 69% 78.1% 87.8% 72% 77.4% 77.4% 60% 72.2% 78.7% 76.9% 65.6%

Well Child Visits in the First 15 months of Life (W15) – Zero visits * 1% 1.1% 2.4% 7% 3.1% 2.6% 3% 5.3% 2.6% 1% 1.1% 0.7% 2% 1.8% 1.1% 1% 0.7% 1.5% 2% 1.7% 1.8% 1.8% 5.6%

Well Child Visits in the First 15 months of Life (W15) – DHMH Five plus six-or-more visits rates (additive)

97% 85.4% 83.0% 71% 70.7% 77.1% 94% 82.0% 81.8% 83% 87.1% 87.3% 78% 82.3% 81.0% 86% 81.3% 86.4% 87% 86.2% 86.0% 83.2% 70.2%

Well Child Visits in the Third, Fourth, Fifth and Sixth Year of Life (W34) 80% 77.5% 74.2% 69% 66.4% 70.0% 88% 89.1% 89.9% 76% 79.1% 73.1% 74% 74.1% 79.4% 73% 77.4% 75.3% 80% 76.3% 75.4% 76.8% 65.3%

Adolescent Well Care Visits (AWC) 57% 50.3% 54.1% 50% 44.6% 49.7% 76% 73.3% 76.1% 60% 51.3% 49.5% 59% 45.7% 52.8% 54% 52.6% 53.4% 59% 52.5% 47.3% 54.7% 42.0%

Respiratory Conditions Appropriate Testing for Children with Pharyngitis (CWP) 68% 67.8% 66.4% 54% 47.9% 69.4% 73% 50.0% 67.3% 71% 74.8% 75.6% 54% 75.8% 78.9% 76% 78.2% 72.0% 65% 67.4% 69.8% 71.4% 58.2%

Appropriate Treatment for Children with Upper Respiratory Infection (URI) 86% 87.1% 85.0% 87% 82.9% 82.9% 82% 87.3% 95.5% 83% 85.1% 84.0% 85% 86.2% 86.3% 94% 96.6% 84.4% 79% 80.6% 80.6% 85.5% 84.1%

Use of Appropriate Medications for People with Asthma (ASM) – Age 5-9 years 88% 91.7% 90.0% NA NA NA NA NA NA 91% 90.5% 91.5% 92% 91.5% 94.0% 89% 87.8% 91.9% 92% 92.0% 91.8% 91.8% 89.3%

Use of Appropriate Medications for People with Asthma (ASM) – Age 10-17 years 89% 88.4% 88.7% NA NA NA 77% 83.3% 72.5% 89% 89.0% 88.7% 90% 92.0% 93.4% 88% 85.2% 88.2% 89% 90.3% 89.8% 86.9% 86.9%

Use of Appropriate Medications for People with Asthma (ASM) – Age 18-56 years 87% 87.9% 86.0% NA NA 92.3% 85% 94.0% 91.7% 85% 86.5% 84.0% 92% 85.1% 92.9% 76% 78.7% 88.8% 86% 86.0% 88.6% 89.2% 84.5%

Use of Appropriate Medications for People with Asthma (ASM) – Total Rate 88% 89.6% 88.6% NA NA 91.6% 83% 91.6% 87.3% 88% 88.7% 87.9% 91% 89.5% 93.4% 86% 85.0% 89.5% 89% 89.6% 90.1% 89.8% 86.9%

Member Access Children and Adolescents’ Access to Primary Care Practitioners (CAP) – Age 12-24 months 97% 96.7% 97.4% 90% 92.2% 91.8% 91% 91.7% 88.3% 96% 96.5% 96.6% 97% 96.9% 96.8% 95% 94.2% 97.8% 95% 95.8% 96.3% 95.0% 93.4%

Children and Adolescents’ Access to Primary Care Practitioners (CAP) – Age 25 months to 6 years

91% 91.1% 91.7% 82% 82.9% 85.5% 89% 88.4% 89.5% 91% 90.0% 91.1% 89% 89.8% 91.6% 85% 86.5% 91.7% 89% 90.8% 92.2% 90.4% 84.3%

Children and Adolescents’ Access to Primary Care Practitioners (CAP) – Age 7-11 years 92% 92.3% 92.6% 81% 82.7% 84.6% 90% 89.3% 93.7% 92% 91.2% 91.6% 92% 92.2% 92.2% 87% 88.0% 92.9% 90% 92.1% 92.2% 91.4% 85.8%

Children and Adolescents’ Access to Primary Care Practitioners (CAP) – Age 12-19 years 89% 88.4% 87.3% 80% 84.9% 81.0% 92% 92.8% 91.9% 88% 89.2% 88.4% 89% 90.0% 88.7% 83% 84.0% 89.0% 86% 88.6% 87.6% 87.7% 82.6%



HEALTHCHOICE ORGANIZATION HEDIS 2009 MEASURES – REPORTED RATES

ACC 2007

ACC 2008

ACC 2009

DIA 2007

DIA 2008

DIA 2009

JMS 2007

JMS 2008

JMS 2009

MPC 2007

MPC 2008

MPC 2009

MSFC 2007

MSFC 2008

MSFC 2009

PP 2007

PP 2008

PP 2009

UHC 2007

UHC 2008

OHC 2009

MARR 2009

NHM 2008

Adults’ Access to Preventive/Ambulatory Health Services (AAP) – Age 20-44 77% 76.7% 77.3% 72% 71.3% 75.2% 74% 76.1% 77.2% 77% 74.4% 79.0% 76% 74.8% 79.2% 77% 77.0% 79.3% 72% 73.8% 75.7% 77.6% 76.8%

Adults’ Access to Preventive/Ambulatory Health Services (AAP) – Age 45-64 84% 83.8% 83.9% 76% 78.6% 78.6% 87% 85.8% 86.9% 85% 85.0% 87.5% 83% 84.1% 85.5% 87% 87.1% 87.5% 84% 85.3% 85.6% 85.1% 82.4%

Women’s Health

Breast Cancer Screening (BCS) 44% 42.0% 41.3% 27% 32.8% 39.9% 56% 64.3% 64.4% 46% 45.6% 46.1% 49% 50.9% 57.6% 42% 42.3% 42.2% 46% 51.4% 51.2% 49.0% 50.0%

Cervical Cancer Screening (CCS) 71% 61.4% 67.9% 44% 48.0% 62.7% 78% 73.8% 78.0% 62% 64.1% 66.3% 58% 64.7% 66.4% 63% 65.6% 63.0% 61% 64.8% 66.1% 67.2% 64.8%

Chlamydia Screening in Women (CHL) – Age 16-20 years 60% 55.6% 58.3% 45% 52.2% 46.4% 69% 79.5% 81.0% 60% 57.7% 58.6% 52% 56.6% 52.0% 57% 58.0% 58.1% 49% 46.0% 50.3% 57.8% 48.7%

Chlamydia Screening in Women (CHL) – Age 21-24 years (Note: Rates for 2008 and prior year were for ages 21-25.)

70% 66.0% 68.7% 57% 65.2% 56.8% 70% 70.9% 73.9% 72% 67.7% 68.2% 56% 64.3% 63.4% 67% 64.7% 63.6% 58% 55.8% 59.3% 64.8% 54.1%

Chlamydia Screening in Women (CHL) – Total, 16-24 years of age (Note: Rates for 2008 and prior year were for ages 16-25.)

63% 59.2% 61.3% 51% 57.8% 50.2% 69% 76.6% 78.7% 63% 60.5% 61.1% 53% 58.9% 55.1% 60% 59.7% 59.4% 52% 48.6% 52.5% 59.8% 50.8%

Prenatal and Postpartum Care Prenatal and Postpartum Care (PPC) – Timeliness of Prenatal Care 98% 90.9% 90.9% 89% 85.0% 87.3% 88% 89.7% 88.4% 87% 84.0% 87.0% 90% 90.0% 87.2% 87% 91.1% 91.4% 88% 91.7% 89.7% 88.8% 81.4%

Prenatal and Postpartum Care (PPC) – Postpartum Care 85% 61.9% 64.3% 52% 52.9% 52.8% 72% 68.2% 72.6% 60% 60.3% 62.1% 55% 67.4% 71.9% 63% 64.6% 63.5% 64% 64.3% 67.6% 65.0% 58.7%

Frequency of Ongoing Prenatal Care (FPC)– Less than 21% of expected visits* 1% 1.3% 2.4% 8% 6.2% 7.1% 4% 1.5% 2.3% 7% 6.2% 3.3% 6% 3.2% 2.7% 6% 3.4% 4.3% 5% 6.0% 4.5% 3.8% 12.5%

Frequency of Ongoing Prenatal Care (FPC)– Greater than or equal to 81% of expected visits

87% 75.7% 74.3% 61% 61.4% 62.2% 80% 84.6% 81.9% 62% 78.7% 71.6% 82% 85.9% 92.1% 70% 75.3% 76.6% 72% 75.3% 78.2% 76.7% 59.3%

Diabetes Care

Comprehensive Diabetes (CDC) – Hemoglobin A1c Testing 78% 73.2% 78.8% 64% 68.0% 67.8% 85% 89.7% 90.7% 76% 78.4% 74.2% 84% 87.7% 85.1% 82% 78.3% 77.7% 74% 74.7% 71.0% 77.9% 77.4%

Comprehensive Diabetes (CDC) – HbA1c Poor Control (>9.0%) * 45% 52.5% 49.6% 50% 52.6% 52.1% 38% 32.6% 30.3% 61% 55.5% 57.9% 35% 38.2% 33.8% 47% 38.7% 47.3% 46% 50.9% 56.4% 46.8% 47.7%

Comprehensive Diabetes (CDC) – Eye Exam (Retinal) Performed 73% 57.5% 50.1% 43% 43.3% 52.1% 72% 75.3% 77.2% 54% 54.4% 65.8% 63% 66.2% 72.2% 55% 63.3% 54.6% 57% 58.2% 65.9% 62.6% 50.1%



HEALTHCHOICE ORGANIZATION HEDIS 2009 MEASURES – REPORTED RATES

ACC 2007

ACC 2008

ACC 2009

DIA 2007

DIA 2008

DIA 2009

JMS 2007

JMS 2008

JMS 2009

MPC 2007

MPC 2008

MPC 2009

MSFC 2007

MSFC 2008

MSFC 2009

PP 2007

PP 2008

PP 2009

UHC 2007

UHC 2008

UHC 2009

MARR 2009

NHM 2008

Comprehensive Diabetes (CDC) – LDL-C Screening 73% 72.7% 74.5% 57% 64.9% 66.9% 84% 90.3% 93.3% 76% 72.7% 73.9% 80% 82.8% 81.7% 72% 73.7% 73.9% 74% 71.8% 71.5% 76.5% 70.9%

Comprehensive Diabetes (CDC) – LDL-C Control (<100 mg/dL) 37% 33.5% 34.9% 20% 27.8% 28.1% 53% 48.2% 47.2% 27% 28.6% 28.9% 43% 42.3% 43.8% 38% 37.5% 42.5% 36% 30.2% 29.2% 36.4% 31.4%

Comprehensive Diabetes (CDC) – Medical Attention for Nephropathy 83% 80.3% 78.8% 63% 75.3% 75.2% 91% 95.9% 93.3% 79% 74.8% 75.8% 85% 87.4% 86.6% 77% 83.9% 78.3% 75% 77.6% 73.7% 80.2% 74.4%


26% 31.1% 27.2% 16% 25.8% 25.6% 29% 25.9% 23.6% 26% 25.8% 25.6% 36% 31.0% 36.3% 45% 35.8% 33.6% 26% 26.0% 28.2% 28.6% 29.6%


56% 56.8% 54.7% 41% 40.2% 45.5% 53% 52.1% 47.2% 45% 49.2% 51.2% 61% 63.3% 65.7% 66% 65.2% 58.8% 50% 55.7% 55.7% 54.1% 55.5%

Ambulatory Care (Utilization)

Ambulatory Care (AMB) – Outpatient Visits 374.0 330.5 364.2 375.2 380.0 382.2 365.1 367.3 317.8

Ambulatory Care (AMB) – Emergency Department 60.3 88.0 78.8 71.8 76.6 62.4 59.3 71.0 60.9

Ambulatory Care (AMB) – Ambulatory Surgery 6.5 13.5 14.0 9.0 13.3 10.8 9.1 10.9 5.5

Ambulatory Care (AMB) – Observation Room Stays 2.0 1.8 2.4 1.5 0.3 3.7 1.4 1.9 2.0

Call Services

Call Answer Timeliness (CAT) 67% 52.0% 75.8% 90% 85.7% 91.4% 85% 86.0% 89.9% 76% 74.5% 82.7% 86% 84.2% 94.3% NR NR 68.2% 60% 89.1% 81.5% 83.4% 79.4%

Call Abandonment (CAB) * 10% 9.3% 3.6% 1% 1.1% 0.8% 14% 3.9% 3.3% 3% 2.9% 2.0% 2% 2.2% 1.6% NR 5.0% 4.2% 8% 1.2% 3.1% 2.7% 5.5%

* A lower rate indicates better performance. ACC = AMERIGROUP Community Care MARR = Maryland Average Reportable Rate DIA = Diamond Plan Coventry Health Care of Delaware NHM = National HEDIS Mean

JMS = Jai Medical Systems, Inc.

MSFC = MedStar Family Choice, Inc.

MPC = Maryland Physicians Care PP = Priority Partners

statewide executive summary€¦ · a plan to audit data sources used for hedis. hedis roadmap...

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